Patient Presentation
A 3-year-old male came to clinic for his health supervision visit.
When discussing dental health the father asked if he should be using adult toothpaste that contained a whitening ingredient.
The boy had seen a dentist twice, and he and his father were doing toothbrushing twice a day with barely a smear of toothpaste on the brush.
He had no caries and a fluoridated water supply.
The pertinent physical exam showed a healthy boy with normal growth and developmental parameters. His oral examination was normal.
The diagnosis of a healthy child was made.
The family was counseled that this was probably okay as long as just a smear was used.
The pediatrician also reminded the family that the child was due for another professional dental examination.
Later, she did a PubMed literature search and looked at various professional society recommendations but could not find an answer.
She consulted one of her dental colleagues who gave her a common sense approach which did not recommend a whitening toothpaste but only a fluoride containing toothpaste.
She then called the family back and updated them on what she had learned.
Discussion
Dental health is important to the overall health of children and adults.
Brushing twice a day with a topical fluoride toothpaste has been showed in meta-analyses of randomized controlled trials to decrease the incidence of dental caries in infants and toddlers.
Periodic dental evaluation is also important. The first dental appointment is recommended at no later than 6 months after the first tooth eruption and no later than 12 months of age even if no teeth have erupted.
The first commercially available fluoride-containing toothpaste was Crest® in 1955.
Since then other ingredients have been added to toothpastes to improve removal of surface stains and improve tooth appearance.
These include polishing and chemical chelating agents.
Bleaching agents applied by dental professionals in the dental setting, or prescribed for home use, are common. The whitening agent most commonly used is carbamide peroxide in various concentrations.
Over the counter whitening agents usually use hydrogen peroxide again in various concentrations. These over the counter whitening agents are usually in the form of whitening strips that are applied to the teeth or whitening gels.
Studies of whether or not home whitening agents work have depended on the methods used. One study found the whitening strips to be better for improving whiteness than the gels or control.
Other studies have found whitening strips to cause no changes in the histomorphology or microchemical composition of the matrix, but did have some changes in the fluorescence due to reducing background luminescence.
The American Academy of Pediatric Dentistry (AAPD) recommends consulting with dentists before judicious use of bleaching for discolored teeth in children and adolescents. Tooth sensitivity and irritation are common side effects to bleaching. Root reabsorption can also occur with bleaching.
The AAPD also points out that most studies of whitening have only been done in adults.
Learning Point
A PubMed literature search and searching of the American Academy of Pediatric Dentistry, American Dental Association and the American Academy of Pediatrics clinical guidelines did not identify a specific answer to what specific type of toothpaste was recommended.
The AAPD only specifies that a fluoride containing toothpaste should be used.
A discussion with a pediatric dental colleague provided the following common sense approach:
- A toothpaste should contain only the ingredients that a child or adult needs or desires. Most children only need the anti-cavity affect that a fluoride toothpaste provides.
Whitening agents may cause tooth sensitivity and may contain more abrasives that could potentially wear the thinner enamel found on children’s teeth.
Therefore whitening agents are not recommended. - The usual biggest concern with toothpaste is the potential ingestion of excessive fluoride by children, which can be helped by using only a smear/small amount of toothpaste.
- A toothpaste designed for children is generally recommended because it has a smaller dose of fluoride than adult toothpastes.
- A children’s toothpaste is often more accepted by children because they have milder flavors also. Mint flavors tend to be too “spicy” or strong for children and they may reject tooth brushing.
Cinnamon flavors may cause mucosal irritation in children and adults.
Questions for Further Discussion
1. What are the indications for fluoride supplementation?
2. How can pediatric health care providers assist dental professionals to provide dental care to patients?
3. What causes tooth discoloration?
Related Cases
- Disease
- Toothpaste
Child Dental Health
Cosmetics
Dental Health
- Symptom/Presentation
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for this topic: Child Dental Health and at Pediatric Common Questions, Quick Answers for this topic: Dental Care
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American Academy of Pediatric Dentistry. Policy on Dental Bleaching for Child and Adolescent Patients.
Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/P_Bleaching.pdf (rev. 2004, cited 12/13/2007).
Duschner H, Gˆtz H, White DJ, Kozak KM, Zoladz JR.
Effects of hydrogen peroxide bleaching strips on tooth surface color, surface microhardness, surface and subsurface ultrastructure, and microchemical (Raman spectroscopic) composition.
J Clin Dent. 2006;17(3):72-8.
Garrison GM, Loven B, Kittinger-Aisenberg LG. Clinical inquiries. Can infants/toddlers get enough fluoride through brushing? J Fam Pract. 2007 Sep;56(9):752 – 754.
Gˆtz H, Duschner H, White DJ, Klukowska MA.
Effects of elevated hydrogen peroxide ‘strip’ bleaching on surface and subsurface enamel including subsurface histomorphology, micro-chemical composition and fluorescence changes.
J Dent. 2007 Jun;35(6):457-66. Epub 2007 Mar 6.
Lo EC, Wong AH, McGrath C.
A randomized controlled trial of home tooth-whitening products. Am J Dent. 2007 Oct;20(5):315-8.
American Academy of Pediatric Dentistry. Policy on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children.
Available from the Internet at http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf (rev. 2007, cited 12/13/2007).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Date
January 21, 2008
Pediatric Education 